Bursaries Awarded in 2015
Final Year Medical Student, University of Bristol Medical School
I divided my 8-week elective in gynaecological oncology between surgical oncology and clinical oncology. My clinical oncology experiences included outpatient clinics (both medical and clinical oncology), radiotherapy planning meetings, brachytherapy planning and treatment sessions and weekly MDT meetings. I particularly enjoyed the collaborative problem solving aspects of MDTs and the academic discussions which arose from complex cases. For instance, one patient with endometrial cancer also had a recent history of colon cancer which was treated with pelvic external beam radiotherapy. This recent course of radiotherapy had implications for her primary and adjuvant management (in terms of adhesions encountered during surgery and that it was not appropriate to re-irradiate her pelvis).
The latter half of my elective was more or less dedicated to project work. Six months before starting my elective, I had organised to undertake an audit to identify patterns of failure in lymphovascular space invasion (LVSI) positive, lymph node negative endometrial cancer patients treated with surgery alone or post-operative radiation therapy (which included external beam radiotherapy and/or vaginal vault brachytherapy). The project was very stimulating and educational. For those interested in undertaking elective projects, my advice would be to refine your protocol as much as possible before you begin the elective, i.e. to outline exactly which data variables are needed to run the enquiry. One of the main problems I encountered was the lack of clarity regarding which variables needed to be collected (I collected unnecessary variables and neglected important ones; therefore I had to return to the original data sets on multiple occasions which wasted a lot of time!)
My elective has positively reinforced my desire to pursue a career in oncology. Having had a longstanding interest in oncology but limited exposure to clinical oncology at undergraduate level, I felt it was important for me to undertake an elective in this specialty to rule it in/out as a potential career choice. As a result of my elective, I feel I am now in better position to become involved in similar projects and apply for specialty training posts in the future.
I am sincerely grateful to the Royal College of Radiologists for supporting my elective placements.
Year 3 Medical Student, University of Cambridge Medical School
I spent my elective in Duke University Hospitals, North Carolina shadowing doctors in the Haematological Malignancies and Cellular Therapies units. I have long been interested in academic medicine, and, in particular becoming an academic haematologist/oncologist. I wanted to learn more about the specialty, and gain an insight into the up-to-date management of haematological malignancies. Additionally, I wanted to get involved in a clinical research project whilst attached to the unit. This would give me a chance to learn in depth about a topic that I was interested in, as well as contributing to the unit and the hospital as a whole. I hoped it will give me an insight into clinical research design and planning and illustrate some of the demands on an academic oncologist.
I was initially given a data trawl project that would help identify a biomarker to better prognosticate outcomes of autologous stem cell transplant (SCT) in multiple myeloma patients. However, on arrival at the first week my elective my supervisor had a more pressing project on a Phase I/II clinical trial being carried out in the centre and suggested I work on that instead. There were dozens of clinical trials being run in the centre and as I worked under the supervision Dr Gasparetto and Dr Rizzieri, I got an insight into the complexities of trial design and recruiting patients in general.
What was striking for me was significance of the physician’s communication skills during these consultations. The patients we met had often travelled across many states in search of cure for their disease. Their hopes and expectations were precariously high. The doctor had the duty to explain the nature of trial and successfully consent them, without accidentally giving them any false hope.
The clinical experience I had on elective was fantastic- I met patients with a whole host of complaints, and saw several cases that I may not come across again in my career. The haem malignancies unit was divided in to two halves – transplant vs. non-transplant. This was my first opportunity to learn more about stem cell transplant. The bread and butter of the unit were patients with non-hodgkin’s lymphomas, AML and multiple myelomas. I also saw rarer entities like mycosis fungoides and non-malignant conditions such sickle cell disease, SCID, IPEX syndrome.
It was inspiring to see some of the unique nurse led research programs run by the centre with the aim of improving patient’s quality of treatment. One particular study was into providing most of the chemo and transplant treatment from the day hospital as an outpatient service. This allowed autologous stem cell transplant patients to live in the comfort of their own home, or nearby temporary residence with their designated family member who was to be their carer. If you are eligible to receive your own cells, you may spend no time in the main hospital as in patient. Many of these patients had received several rounds of chemotherapy before, had often had extended stays in hospitals before being referred for a transplant. One 65yr mother of two, explained to me during her follow up clinic that the privacy and dignity of being able to stay in her own home with her daughter had made her 3 months of intense transplant treatment for AML much more bearable.
I also saw some niche sub-specialties during my 7 weeks - Dr Tuchman’s clinics were dedicated primarily to amyloidosis. I met patients with every subtype of amyloidosis in a single day! I learnt about an ongoing clinical trial using a drug (Patisiran) acting via novel mechanism (RNAi) in the treatment of familial TTR amyloidosis.
Further, I was able to take part in the weekly multidisciplinary meetings in which complex in-patients and out-patients were discussed. Some examples of diagnostically challenging cases I encountered include: 32yr old AML patient treated with allo-transplant, presenting in headaches and seizures which was diagnosed as PRES following imaging and a 54yr old transplant patient who presented with an atypical rash following a tick bite while hiking. In the latter it was difficult to determine whether the rash was indeed tick related, or if it was GVHD.
Although I was formally attached to the adult haem-malignancies unit, I took the opportunity to work with paediatric transplant unit, and cardiology teams during the final 2 weeks. Some of the saddest and yet inspiring moments came from ward rounds on the paediatric in-patient unit. One child with FoxP3 deficiency, undergoing cord-blood transplant was celebrating his first birthday in hospital, having never left the unit since his birth due to his immunodeficiency. I was introduced to a cardiologist via a joint amyloidosis clinic who then invited to me join him in the emergency department the following week with the on-call team. This put me back in some familiar ground. After weeks of seeing complex immunosuppressed patients, it was back to taking histories of chest pain and dyspnoea. I was able take part in teachings on reading ECGs, ECHOcardiograms, and assessing patients with arrhythmias. Here too I saw some complex diseases. I met a 24yr old leukemic presenting heart failure in the midst of her chemotherapy and 22yr old year presenting Eisenmenger syndrome. I also learnt about the longer term complications of radiotherapy when I clerked a patient with coronary artery disease who had previously been treated for Hodgkin’s.
In the midst of these wide-ranging clinical experiences I continued to work collecting data on the trial of bendamustine/pomalidamide/dexamethasone regimen for patients with refractory myeloma. I worked with my supervisor to learn how a variety of biomarkers are used to clinically track the disease – e.g. serum M-protein, immunofluorescence, clonal cells in bone marrow, urine bence-jones levels etc. We went through patient notes to assess their clinical response at each cycle of the therapy. I also collated the different adverse events and toxicities that occurred and learned how to use the CTCAE grading system to classify these. While this is still an ongoing trial, we were able to analyse the current data to determine the MTD of the BPD combination therapy as well calculate Overall response, Time to progression (TTP), progression free survival (PFS), time to next therapy for our cohort of 27 patients. The results have been submitted to the American Society of Hematology meeting in December 2015. Although, this project was small in nature, I gained more experience in gathering and analysing clinical trial data.
My elective was hugely educational: I learnt about haematological oncology as a specialty, I saw many fascinating patients, experienced some of the advantages and disadvantages of medical practice in a private health care system. This was my first visit to the USA. It was with the view that I might one day apply for a fellowship in the States that I went. In this light, my elective was somewhat of an information gathering exercise. I wanted to gain some insight into what life would be like as a trainee at a competitive American hospital and compare to experiences at home.
While there was high quality, patient centred care being provided in Duke, I understood that these treatment options were only open those with sufficient insurance cover. I also saw some inefficient medical practice at work, as almost all patient with chest pain, regardless whether the history sounded cardiac in origin, were having troponin levels checked. Such defensive practice, understandably driven by the medicolegal environment in the US healthcare system was nevertheless leading to extremely slow turnover of patients in the emergency room. Ultimately, some patients were having to wait for 8-9hrs to be seen in the ED. On the other hand, I found that most doctors I met, regardless of specialty were keen to teach and take on a student to shadow them. Their enthusiasm to teach was not dampened even by the long-shifts they worked. The most striking aspect of the system I found was in fact, working in Duke was not very different from teaching hospital Cambridge. The hospital set-up, shifts, terminology, care pathways etc. were almost identical. The main difference was that: 1) there was tendency towards subjecting patient to some excessive investigations and 2) only patients with insurance were treated. Thus, I found while the US health system had the potential to provide excellent training ground to learn about variety of diseases and treatments, it is in a public system like the NHS where I wish to work long-term.
Bursaries Awarded in 2014
Year 5 Medical Student, Peninsula Medical School
I undertook a 5 week audit project at Velindre Cancer Centre, Cardiff during the summer of 2014. I was looking at the stereotactic ablative body radiotherapy service (SABR) for non small cell lung cancer (NSCLC). The service had been running for about 2.5 years by the point I carried out the audit with a total of 43 patients treated. This is a relatively small number in comparison to some of the larger centres in the UK which have been running SABR services for NSCLC for longer.
Whilst at the cancer centre I regularly attended weekly radiotherapy meetings for lung cancer. I was exposed to complex cases and observed discussions around treatment decisions for patients with lung cancer.
Upon completion of the project I returned in October 2014 to present my findings to all the Lung Clinical Oncologists and a few specialist nurses at their site specific team meeting. My project has been incorporated into a larger audit of radical radiotherapy for South Wales which is currently ongoing. I went on to present the results as a poster at the British Thoracic Oncology Group 2015.
Bursaries Awarded in 2013
An undergraduate from the University of Cambridge School of Clinical Medicine
'During the Summer of 2013, I completed a three week elective in Paediatric Haematology-Oncology at UCLA Hospital in Los Angeles. The placement provided me with an excellent opportunity to experience Oncology in the paediatric setting and appreciate a different health system. I gained insight into both outpatient and inpatient care and attended a wide range of clinics encompassing a number of different malignancies. I also attended a number of general haematology clinics which allowed me to appreciate the long term management of patients with haematological disorders.
In addition to the clinical experience, I was able to attend a number of seminars and tutorials which furthered my understanding of important issues relating to the treatment of cancer. I feel that I have gained a much deeper understanding of oncology and this will undoubtedly help to inform my career choices in the long term. The placement has also been one of the highlights of my medical student years'.
An undergraduate from the University of Sheffield Medical School
'My personal experience as a teenage cancer patient undoubtedly provided me with the biggest motivating factor in my decision to study medicine. Having become fascinated by the pathophysiology of the disease and the different healthcare models that are employed to treat teenagers and young adults (TYA) in the UK I decided that it would be interesting to see how these also differ in another country. As I have my complemented my medical studies with various areas of research I worked with one of my mentors, the CEO of The Teenage Cancer Trust, to arrange an elective to visit California - the location of the relatively new TYA oncology movement in the USA.
The elective was arranged within the University of California system, both in Los Angeles and Irvine. Initially I was based at Children's Hospital of Orange County (CHOC). In addition to the wards, I was also able to spend time within outpatients, and in theatre to see bone marrow biopsies, lumbar punctures and the administration of intrathecal chemotherapy. I also rotated at the main UCLA campus and worked at the UCLA Medical Center, Santa Monica - this is the site of the very first TYA cancer centre in the USA - the UCLA Daltrey/Townshend Teen Cancer Program. This is very much based on the UK model of age appropriate care - dedicated units in hospitals where young cancer patients are treated together. These include everything from computers, games and TV consoles to the staff who are specially trained in treating young people.
It was enlightening to spend time with the Simms/Mann UCLA Center for Integrative Oncology. Here psychologists and social workers help to address the holistic needs of patients and their families through cancer. Exposure to the survivorship clinics here was also a crucial part of my visit. During one visit a patient and their family could see an oncologist, an endocrinologist and a psychiatrist.
While I gained a great deal from the elective I was fortunate to be able to share my own knowledge and the research that I have been involved in. The UK is widely seen as the leading country in the world within the context of TYA oncology and so countries like the US are looking to us to help improve and expand on their existing infrastructure. I was pleased to be able to fully maximise my time on placement and with all of the experiences that I gained while travelling I can honestly say that it was the trip of a lifetime'.